Mercy

CHAPTER 25

The day after her meeting with Brandon Stahl, Julie made the short three-block walk from the ICU in the Tsing Pavilion to the Barstow Building, home to White Memorial’s famed Center for Cardiac Angiography, Angioplasty, and Arrhythmias, known as the C2A3. It was also where the director of C2A3, Dr. Gerald Coffey, kept a private office.

Dr. Coffey had been with White Memorial since the Pleistocene era, some staffers joked, but back in his day he had been at the forefront of new technical advancements in the field. He was a pioneer of acute myocardial infarction angioplasty, and had helped to perfect the procedure a decade before it became routine. He had completed his clinical training in cardiology at Harvard Medical School, his residency at Mass General Hospital, and a fellowship in cardiac medicine at Johns Hopkins, all best of the best.

The other cardiologists Julie had spoken with about Sam’s case suggested she direct her inquiry to Dr. Coffey, but he had been unavailable until now. It was good fortune that his schedule cleared at a time when she had new and perhaps startling information to share.

Julie’s legs ached as she hurried to make her appointment on time. She had spent the past five hours on her feet and desperately wanted to decompress in the hospital cafeteria with a cup of mud-colored coffee and The Boston Globe. Rare was the morning Julie had time to read the paper, and today was no exception.

Her Wednesday workday had begun just after sunrise, when she met with her ICU nursing staff and respiratory therapists before morning rounds. She was now on an extended lunch break. So far it had been a typically atypical day, with a variety of administrative issues and unpredictable patient ailments.

Julie took the elevator up to the third floor and proceeded down a quiet, carpeted corridor, dimly lit as any casino. She found Dr. Coffey’s office, fourth on the left, and checked the time. One minute before the hour. Good start. She knocked twice, and a voice softened with age told her to enter.

Dr. Coffey’s spacious office had a window and a view of the quad. Julie tried to contain her envy; her office was a refurbished maintenance closet, a quarter the size of this one, without any natural light. Dr. Coffey rose from his chair behind an expansive oak desk, giving Julie a look at his thin frame. He extended his hand. His grip was firm as Julie introduced herself. They had never met, but with so many physicians at White, that was no great surprise.

Everything in the office was impeccably neat, from Dr. Coffey’s desk to the bookshelves, to the fine mane of silver hair that topped a strong, square-shaped face. He wore black plastic glasses with thick lenses that magnified brown eyes set close to a snub nose. Underneath a white lab coat he wore a rose-colored shirt adorned by a solid red tie. The office walls were plastered with framed diplomas and certificates, as well as a large photograph of Dr. Coffey playing golf with the mayor of Boston. Another photo showed him inside the cockpit of a plane he piloted.

“Please have a seat,” Dr. Coffey said. “Can I offer you something to drink? Lemon water, perhaps?”

He has lemon water in his office?

“No, thank you,” Julie said.

Dr. Coffey went to a small refrigerator (he had a refrigerator, too), poured two glasses, and gave one to Julie.

“In case you change your mind,” he said. “Now, what can I do for you?”

“I want you to have a look at this EKG, if you wouldn’t mind.”

Julie produced several printouts from her purse and handed them to Dr. Coffey.

“The patient died,” she said. “These were recorded shortly before death.”

“You pulled this from an electronic medical record, I assume.”

“Yes,” Julie said. “The cloud-based system stores everything now.”

“Cloud-based.” Dr. Coffey said it with contempt. “To me a cloud is something puffy in the sky that one flies through.”

“It’s just a way of storing data,” Julie said, though she did not fully understand the cloud herself. Her son Trevor could explain it to them both.

“Have you ever flown a plane?”

“Can’t say that I have.”

He pointed to the picture on the wall of him in the cockpit of one. “No feeling like it,” Dr. Coffey said. “The only thing that makes me consider retirement is more time in the sky. That’s why I’m very protective of my schedule. Got to make the most of every minute.”

In her mind, Julie rolled her eyes. This was his not so subtle way of telling her to make it quick.

“I hope this won’t take up much of your time,” Julie said.

Dr. Coffey adjusted his glasses and cleared his throat, then took a sip of his lemon water.

“Very well,” he said. “Let me have a look.” He held the eight-by-ten printouts to his face, but did not study any image for long.

“Yes, I see the AVR elevated here, along with the anterior leads V2, V3, V4. Was the patient male or female?”

“Male.”

“Over forty?”

“That’s correct,” Julie said.

“So it’s atherosclerosis disease, buildup of plaque in the arteries.”

“But there’s no evidence of heart disease in the medical record,” Julie said.

“Please,” Dr. Coffey said dismissively. “Ten percent of patients have plaque we can’t see.”

“Can’t see? Really?”

“Think of a Twinkie,” Dr. Coffey said.

Julie looked baffled. “A Twinkie?”

“Yes. I use this analogy with my Harvard students every year. It connects with them. Now, imagine a large tube that has this Twinkie inside it, such that when you bend the tube where the Twinkie is, it cracks open, causing the white filling that represents free cholesterol to pour into the tube. That stimulates the clotting cascade and an acute thrombus forms. The body naturally produces elements like tissue plasminogen activator, which causes the clot to dissolve, and others that break the residual Twinkie plaque down like Pac-Man-gobbling ghosts. When you come back to the tube at the time of doing an angiogram, you find it clear of the filling and the Twinkie. But that’s only temporary. The Twinkie comes back, cracks open again, and gets gobbled up again.

“Now, and I’m just thinking out loud because the EKG is very nonspecific, this could be a coronary artery vasospasm.”

“And that is?”

“Smooth muscle constriction of the coronary artery,” Dr. Coffey explained. “You can have nonexertional chest pain with ST-segment elevation. Patients may perform normally on the stress test, but constricted blood flow could result in ventricular fibrillation.”

“Very well, but have a look at this. It’s the patient’s echo.”

Dr. Coffey reached across his desk and took the printout from Julie’s hand.

“Do you notice the apical ballooning of the left ventricle? This echo was taken around the time the patient began complaining of chest pain.”

“Who is this patient?”

“Donald Colchester.”

Dr. Coffey thought a moment before a look of utter surprise came to his face.

“Colchester? The murder victim from-what? A few years back now. What do you have this for?”

“I’ll explain in a moment.”

“The nurse who killed him-”

“Brandon Stahl.”

“Right, Brandon Stahl, injected his patient with morphine, if my memory serves.”

“You’re correct. That was in the evidence.”

“I don’t have to explain to you that an opiate overdose has a high probability of causing a heart attack, do I?” Dr. Coffey looked at the echo more closely. “In this case I’d say Mr. Colchester had a coronary occlusion of the left anterior descending artery, the one that feeds the left ventricle.”

“So you wouldn’t say this was takotsubo cardiomyopathy?”

Dr. Coffey blinked several times rapidly. “Takotsubo cardiomyopathy? Why would you even say that? Is Mr. Colchester a menopausal woman subjected to some sudden stress event? No, of course not. It is what I said it is.”

“A coronary occlusion of the left anterior descending artery,” Julie said, repeating what Dr. Coffey had just told her.

“That’s right. And what are you doing digging up one of White’s most notorious skeletons, anyway? Does this have anything to do with that failed appeal?”

“In a way,” Julie said. “And I appreciate the word of caution.”

“Not enough to proceed with any, it seems,” Dr. Coffey said.

Julie allowed a slight smile. The Donald Colchester murder was one of the darkest days at White, and Dr. Coffey was right to think her line of inquiry was ill-advised. But some questions demanded answers, just as some convicts deserved their freedom.

“I want to show you something else. It’s the pathology report from my fiancé’s autopsy.”

“Oh dear. That’s right. Your fiancé was in that horrible motorcycle crash. I read that on a news bulletin that went around. I’m terribly sorry for your loss.”

“Thank you. I appreciate it. But have a look at these slides. You can see the same apical ballooning of the left ventricle. And here the ST elevation registers on his EKG.”

Dr. Coffey spent a moment examining the second set of printouts, these belonging to Sam.

“This is just more atherosclerosis. Both these men had heart attacks.”

“Both of them had healthy hearts.”

“You say healthy. Ten percent have plaque we don’t see, remember?”

“The Twinkie.”

“Yes, the Twinkie. But in one of these cases the man was murdered, so there’s no odd correlation here. Again, I’m sorry for your loss, but it is what it is. You hear hoofbeats you think of horses, not zebras, and you certainly don’t think of a unicorn.”

“You’re saying takotsubo is a unicorn?”

“Absolutely! What condition were these men in?”

“One had end-stage ALS, and the accident left my fiancé quadriplegic.”

“So they had long-term, chronic stress for sure.” Dr. Coffey paused. “But a sudden stress event? I doubt it. Wait a minute. I need to refresh myself.”

From a bookshelf, Dr. Coffey pulled a large medical tome and opened to a page he found using the index.

“Here we go,” he said. “Yes, that’s what I thought. Takotsubo is an abnormal contraction of the left ventricle that extends beyond just one blood vessel. And here’s the important part: a stressful trigger will cause an abnormal surge in adrenaline, constricting coronary arteries, which results in poor blood flow downstream. As the stress decreases, the arteries open up again, and the angiogram looks normal.”

“Meaning?”

“Meaning if either of them had an acute stress event, which I’m telling you they didn’t, when it was over their arteries would have opened up. Which is why takotsubo is so rarely fatal. These patients were men, not subjected to any sudden stress, who suffered fatal heart attacks,” Dr. Coffey said. “That’s not takotsubo. It’s an undiagnosed coronary disease in the case of your fiancé, and murder in the other.”

“Could you maybe pass these around to get some other thoughts?”

Dr. Coffey’s face became a little red. “I don’t have time to go through this again, and honestly I don’t need you badgering my cardiologists with your questions.”

“I’m sorry, I was just trying to understand.”

“Oh please,” Dr. Coffey said. “A graduate from a state medical school would understand.”

Julie tried not to look offended. “I happen to have graduated from a state medical school. UMass Medical School, to be exact.”

Dr. Coffey pursed his lips together. “Then try to understand this. We’re all under pressure to perform financially and do what’s in the best interest of our patients. I suggest you focus on caring for yours, and let me focus on caring for mine. I gave you the answer, so there’s nothing more to say. I have another appointment elsewhere, so I’m going to have to end our meeting now.”

“I’m sorry to be a bother,” she said.

“And I’m going to hold on to these,” Dr. Coffey said, slipping the printouts into his desk. His expression bordered on apoplectic. “White Memorial doesn’t need a PR nightmare from some rogue ICU doctor making unsubstantiated claims about things she knows nothing about. And I sure as hell don’t need Roman Janowski breathing down my neck thinking my department in any way condones your misguided exploration.”

Julie stood shakily and backed toward the door. Coffey’s rancor had jarred her, leaving her a bit off-kilter. This qualified as a sudden stress event, for sure. Maybe her heart would have a sudden onset of apical ballooning.

“Now, I’m sorry for being so harsh,” Dr. Coffey added in a much softer tone. “You’ve lost your fiancé and I understand your need for closure. But I have a department to run, and what you’re doing with this Colchester business threatens to make my life and my job more difficult.”

“I assure you that’s not my intention.”

“Then prove it by dropping this matter entirely. Colchester was murdered, and his killer is in prison where he belongs. Your fiancé died of undiagnosed heart disease. That’s it. That’s the story. Though I do find it interesting.”

“What is that?”

“You have a bit of a reputation here at White as a crusader, so I know all about your stance on patient self-determination. Do you condone what Brandon Stahl did to poor Mr. Colchester?”

“I am in favor of examining the laws with regard to a patient’s right to die. I don’t condone murder.”

“Very well. At the risk of being a bit cold-hearted here, I would think part of you would be grateful your fiancé was no longer suffering.”

Julie seethed on the inside, but managed to keep her anger in check. “To be candid, Dr. Coffey, I don’t need you to tell me what to think or feel, thank you very much. And you can have those printouts if you want them. I’ll print out more if I need.”

Julie stormed toward the door, but stopped when Dr. Coffey called her name. She turned around, expecting him to apologize.

“Remember, Julie, unicorns don’t exist.”

Julie thanked him for his time, even if she chose not to believe him.